2.0 Analysis 2.1 Introduction The flight crew did not fly this approach in accordance with SOPs, and the tail of the aircraft struck the runway on landing. The tail struck the runway because the speed brakes were still deployed, which resulted in a high angle of attack to maintain required lift and a consequent high aircraft pitch angle. The analysis will discuss flight crew attitudes and procedures, company standard operating procedures (SOPs), CRM, and aircraft warning systems. 2.2 Flight Crew Attitudes and Procedures The incident might have been avoided if the captain or the first officer had complied with the Boeing 757 aircraft flight manual and company SOPs, which state that a missed approach must be initiated if the aircraft is not stabilized on the approach and in the landing configuration, at the latest, by 500 feet agl. The captain and first officer both acknowledged that they were aware of this rule, and were aware that at 500 feet agl, on this approach, the approach was not stabilized. The captain's decision to continue the approach even though the approach was not stabilized at 500 feet agl was based on his evaluation that, despite the deviations, he could salvage the approach. The first officer, although aware that the aircraft was not stabilized at 500 feet agl, was confident that the captain was in complete control and was taking effective action to complete the approach and landing. Given his limited experience in line operations and limited time in the company, he was reluctant to suggest to an experienced company check pilot that he execute a missed approach. The result is that neither pilot initiated a missed approach. If the tailstrike had not occurred on landing, with the resultant aircraft damage, no one else would have been aware of the anomalies associated with the approach and landing since no report was required and neither pilot considered it necessary to write one. In addition, the sounding of a GPWS warning on approach is also an event requiring a go-around, according to SOPs. That a missed approach was not conducted is considered a lack of application of the procedures involved in the operation. 2.3 Occurrence Reporting The company did not have a policy regarding the types of unusual circumstances that would prompt a flight crew to file a report; however, given the warnings, cautions, and GPWS activity during the final approach on this occurrence, the captain should have considered this flight to be somewhat unusual. The ILS and/or the aircraft autopilot's inability to properly fly the glide slope could have been reported to allow follow-up action to take place. The anomalies were eventually reported after the aircraft damage was discovered. 2.4 Standard Operating Procedures The captain chose to deploy the speed brakes shortly after glide slope interception instead of following the approved Boeing AFM procedure and company SOP of lowering the landing gear and flaps to maintain the desired speed. On this approach, the glide slope interception was coincident with the OM/FAF, which is when the landing gear would normally be lowered. The procedure of delaying extension of the landing gear until the outer marker or final approach fix, or approaching 1,000 feet agl if inside these positions, is included in the company SOPs, and is in accordance with national and international procedures. After the occurrence, the chief pilot sent a letter to all pilots reinforcing the procedure. A configuration warning will activate when the aircraft descends below 800 feet agl if the landing gear is not locked down. During an approach at normal rates of descent, if the landing gear were selected at 1,000 feet agl, it would be locked down by 800 feet. The landing gear was selected down at about 700 feet agl, and the warning activated. This warning undoubtedly added to the confusion of the flight crew caused by all of the other warnings and cautions. Neither the manufacturer nor the company approves of using the speed brakes on final approach, whether in instrument or visual conditions, to keep the speed back. It is recognized that there is potential for forgetting the speed brakes in the deployed position, which greatly increases the possibility of a tailstrike on landing; hence, the rule that the speed brakes be retracted by 800 feet agl on descent. The occurrence demonstrates that the deployment of the speed brakes, the delay in lowering the landing gear and flaps, and the incomplete landing check which allowed the continued deployment of the speed brakes contributed directly to the incident and the damage. There were, seemingly, adequate check-lists, check-list procedures, standard operating procedures, and aircraft system cautions and warnings in place to prevent this occurrence. However, the manner in which the captain flew the aircraft and completed his duties as the pilot-in-command circumvented all of the safeguards. The first officer, new and inexperienced with the aircraft and the company, did not adequately monitor that the captain was conducting the approach properly, and, when required, he did not effectively or aggressively convey his concerns to the captain. 2.5 Crew Resource Management (CRM) CRM is interaction of the crew, especially the flight crew during flight, with the object of maintaining situational awareness and flying the aircraft in accordance with procedures and safe practices. Effective CRM is marked by good communication, assertiveness of crew members, leadership on the part of the captain, adherence to company procedures and policies, and good decision making. Based on the information provided by the flight crew and the FDR data, effective CRM was absent in the late stages of this flight. In particular, the captain did not re-brief the approach when he decided to use the ILS; he did not keep the first officer updated on his intentions; he did not perform the landing check properly; his actions at the 500-foot agl stabilization point and in response to the GPWS warning were inappropriate; and his analysis of the situation was inconsistent with the warnings and input that he was receiving from the aircraft systems. By not involving the first officer more directly, the captain made it difficult for the first officer to provide effective feedback during the approach. The first officer, as well, did not practise effective CRM. He did not make the mandatory calls on deviations which were occurring during the final approach, specifically the high rate of descent, high speed, excessive glide slope deviation, and excessive aircraft pitch attitude; he did not reinforce the 500-foot stabilization point by advising the captain that the approach was not stabilized; and he did not ensure that the landing check was completed properly. In summary, the first officer was ineffective in correcting the deficiencies during the approach. This situation could have been attributable to the first officer's inexperience with the company and on the aircraft, and perhaps he extended too much professional courtesy to the captain, given his status with the company. The first officer had instructed CRM during his military flying, had taken the company CRM course, and had over 5,000 hours flight time. One could expect him, with this background, to have been more active and assertive during the approach. The captain got behind on this approach because he concentrated more on the visual approach than on the ILS approach that the autopilot was flying, and he did not re-brief the approach or advise the first officer when he changed his mind and coupled the autopilot to the ILS. From that point, the first officer was in a poor position to contribute to the approach because he was unsure of what would be required of him due to his inexperience on the line. The first officer's reluctance to prompt the captain throughout the approach probably contributed to the captain's sense that the situation was under control. When the captain coupled the autopilot to the ILS, he did not adjust his monitoring technique to take into account how the autopilot was coping with the ILS approach. Instead, he continued to devote more attention to external cues, which would have been less precise than information displayed on aircraft instruments. This mixing of monitoring cues can lead to confusion and compound problems when difficulties arise during an approach. It should be understood by both members of the flight crew, before the approach is commenced, what procedures will be followed, thereby assisting in the maintenance of situational awareness. When the ILS became unreliable and the aircraft increased its rate of descent, the captain's detection and interpretation of the events was probably slower than would have been the case if he had been devoting the majority of his attention to the automated system. The captain's situational awareness was degraded to the extent that, for the remainder of the approach, he was reacting to the situation rather than anticipating and controlling it. He eventually defaulted to the visual approach, by disengaging the autopilot, in order to salvage the approach and landing. The first officer's appreciation of the situation differed from that of the captain's. In particular, he was unsure of the captain's intentions; the captain had briefed the approach and had then changed the plan without re-briefing. Also, the first officer's limited time on the line and limited exposure to this type of approach gave him few references for comparison; therefore, he was not able to assist the captain. The first officer was aware of some aspects of their situation, but, without effective communications with the captain, he was reluctant to act. This interaction between the captain and the first officer resulted in confusion, breakdown in crew functions, rushed and incomplete procedures, and late, inappropriate decision making, all of which contributed to the tailstrike. 2.6 Aircraft Systems The aircraft performed as it was designed to during this approach and gave the warnings, cautions, and messages required under the circumstances. It appears that the captain and first officer were confused by the many warnings that occurred in such a short period of time. They did not react to the EICAS AUTOPILOT caution and associated indications, and could not recall exactly what warnings and EICAS messages they received. Nevertheless, given the uncertainty of the status of the ILS, the captain could have discontinued its use when the aircraft started to descend below the glide slope and at an excessive rate. Eventually, the captain disengaged the autopilot and attempted to salvage the approach and landing. Ironically, the systems in the aircraft that are there to assist the flight crew in maintaining situational awareness (e.g. EICAS, GPWS) became a hindrance to communication on the flight deck because of the volume and frequency of aural and visual signals being emitted during the approach. Both crew members probably knew that the aircraft systems logic will issue a configuration warning at 800 feet agl if the landing gear is not extended, that a speed brake caution will be issued if the speed brakes are extended below 800 feet agl, and that the GPWS will issue warnings regarding the glide slope and terrain for the conditions of the occurrence approach. However, the crew's responses to the warnings and the fact that they did not anticipate the warnings indicate either of the following: they did not have an adequate appreciation of the warning systems and their interactions in a dynamic situation; or they were so far behind the aircraft that they did not even think that the manner in which the approach was being flown would trigger the warnings and cautions. Whether it was inadequate appreciation or being behind the aircraft, or both, the situation was unusual, especially for a company check pilot and a recent graduate of the company's initial training program. 3.0 Conclusions 3.1 Findings The flight crew was certified, trained, and qualified for the flight in accordance with existing regulations. There was no evidence that physiological factors affected the flight crew's performance. The aircraft was serviceable and provided the appropriate warnings and cautions to the flight crew during the approach. The ILS at Acapulco was NOTAMed off the air; however, the flight crew did not receive this NOTAM. The flight crew were unsure of the ILS status, and their attempts to confirm verbally its status were unsuccessful. The AUTOPILOT caution was probably the result of the ILS glide-slope transmitter not functioning properly. CRM principles were not in evidence during the final approach, despite both members of the flight crew having received CRM training. In order to keep the speed back after glide slope interception, the captain deployed the speed brakes, instead of lowering the landing gear and flaps in accordance with the AFM and SOPs. The flight was not stabilized by 500 feet agl, and the captain did not perform a go-around as required by company procedures. The first officer did not make the mandatory deviation calls required by SOPs during the approach and landing. The captain used an inappropriate monitoring technique during the visual approach with the autopilot coupled to the ILS, which resulted in confusion and delayed decision making. The captain did not keep his hand on the speed brake lever as recommended by the manufacturer and the SOPs. The flight crew completed the approach and landing with the speed brakes deployed, which resulted in the tailstrike; the crew did not monitor the pitch angle on landing. The company did not have a policy regarding the types of unusual circumstances that would prompt a flight crew to file a report with regard to a flight. 3.2 Causes The flight crew had not retracted the speed brakes prior to landing, which resulted in a tailstrike. Contributing to the occurrence were actions which deviated from company standard operating procedures and the aircraft flight manual, ineffective crew resource management, and incomplete check-list procedures. 4.0 Safety Action 4.1 Action Taken 4.1.1 Operator Action Two days after the incident, the operator issued a letter to its Boeing 757 pilots highlighting the main issues arising from the company's analysis of the FDR data. Policies and procedures were reinforced for stabilized approaches by 500 feet agl, gear and flap extension in IMC and VMC, communications, use of ground proximity flap or configuration gear override, and GPWS. In January 1995, another letter was issued stressing the earlier letter and implementing an additional SOP concerning the cancellation of warnings or cautions in the cockpit. The company has reportedly entered into discussions with a major airline to introduce Flight Operations Quality Assurance and is updating its training with respect to automation in the cockpit. The company is also refining its CRM training program. 4.1.2 Transport Canada Aviation Action 4.1.2.1 Managed Drag Approaches As a result of this occurrence and feedback from Canada 3000 pilots, Transport Canada and Canada 3000 reviewed procedures for Boeing 757 managed drag approaches. These procedures were subsequently enhanced to ensure that crews have clear guidance on the technique required and on the need to conduct a go-around if the approach is not stabilized by the minimum altitude specified in the SOP. Company check pilots were briefed about the increased potential for unstabilized approaches that could result from over-emphasis on managed drag approaches. 4.1.2.2 Standard Operating Procedures (SOPs) The new Canadian Aviation Regulations contain requirements pertaining to company SOPs. The SOPs must enable crew members to operate the aircraft within the limitations specified in the aircraft flight manual and must meet the commercial air service standards. Operators will be required not only to establish and maintain SOPs, but also to train and test their pilots in the application of SOPs. 4.1.3 International Civil Aviation Organization (ICAO) Action Analysis of data from recording devices such as digital Flight Data Recorders (FDRs), Quick Access Recorders (QARs), and Health and Usage Monitoring Systems (HUMS) can result in the early detection of safety hazards and the initiation of appropriate corrective measures. Accordingly, in March 1995, ICAO reported its intention to include, as a recommended practice, a requirement that operators establish, in co-operation with their flight crews, a non-punitive performance monitoring programme.